1. Transaction Information
Date of Transfer / Sale: [[Date of Transfer]]
Type of Transfer: [[Sale / Gift / Trade / Inheritance / Other]]
2. Seller Information
Full Legal Name: [[Seller Full Legal Name]]
Address: [[Seller Street Address]], [[Seller City]], [[Seller State]] [[Seller ZIP Code]]
Phone: [[Seller Phone]]
Email: [[Seller Email]]
Driver's License / ID: [[Seller DL/ID Number]] Issuing Jurisdiction: [[Seller DL State]]
3. Buyer Information
Full Legal Name: [[Buyer Full Legal Name]]
Address: [[Buyer Street Address]], [[Buyer City]], [[Buyer State]] [[Buyer ZIP Code]]
Phone: [[Buyer Phone]]
Email: [[Buyer Email]]
Driver's License / ID: [[Buyer DL/ID Number]] Issuing Jurisdiction: [[Buyer DL State]]
4. Vehicle Identification
| Field | Details |
|---|
| Year | [[Vehicle Year]] |
| Make | [[Vehicle Make]] |
| Model | [[Vehicle Model]] |
| Body Style / Trim | [[Vehicle Body Style or Trim]] |
| VIN | [[17-Character Vehicle Identification Number]] |
| Current Odometer Reading | [[Odometer Reading at Transfer]] miles |
| Title Number | [[Current Title Number]] |
| Title State | [[Title Issuing State]] |
5. Odometer Certification
I (Seller) certify under penalty of law that the odometer reading shown above is accurate to the best of my knowledge and that I have not altered or disconnected the odometer.
Check one box only:
- The odometer reading reflects the actual mileage the vehicle has traveled.
- The odometer reading reflects the mileage in excess of the designed mechanical limits of the odometer (the odometer has "rolled over").
- The odometer reading is not the actual mileage. (Warning: The odometer has been repaired, replaced, or is otherwise known to be inaccurate or tampered with.)
Explanation if Box 2 or 3 is checked:
[[Provide explanation of why the reading is not actual or has exceeded limits, or state "N/A"]]
6. Federal Disclosure Requirements and Exemptions
Applicability
This disclosure is required for the transfer of ownership of most motor vehicles. The requirement generally covers vehicles that are less than 20 model years old at the time of transfer.
Exemptions (no disclosure required)
- The vehicle is 20 or more model years old at the time of transfer.
- The vehicle has a gross vehicle weight rating (GVWR) of more than 16,000 pounds.
- The vehicle was not self-propelled (e.g., certain trailers in specific cases).
- The transfer is pursuant to a court order or is a transfer between spouses or certain family members in limited circumstances (consult DMV for exact rules).
Seller has verified the model year and GVWR and confirms the disclosure is required: [[Yes / No - Exempt for reason above]]
7. Vermont-Specific Instructions and Integration with Title Transfer
Vermont buyers and sellers must follow these steps for compliant transfer:
- Complete this disclosure form in full.
- Record the odometer reading on the title assignment section if the Vermont title provides one. If the title is out-of-state or lacks an assignment section, attach this completed statement (or the equivalent Vermont DMV form) when applying for title.
- The buyer must present the signed title (or out-of-state title plus this disclosure) along with other required documents to the Vermont DMV or authorized agent to complete titling and registration.
- Retain copies of this disclosure for both parties' records for at least five years.
Vermont DMV may request additional documentation or an affidavit if discrepancies are noted. Always use the most current official forms available from the Vermont DMV website.
8. Penalties for False or Incomplete Disclosure
Knowingly providing false odometer information or failing to provide required disclosure violates federal law (49 U.S.C. §§ 32705, 32709, 32710) and Vermont motor vehicle laws. Penalties may include:
- Civil fines up to several thousand dollars per violation.
- Criminal penalties including fines and imprisonment.
- Liability to the buyer for damages, including three times actual damages plus attorney fees in certain cases.
- DMV refusal to title the vehicle or administrative sanctions.
Seller and Buyer acknowledge they understand these penalties.
9. Additional Disclosures and Acknowledgments
Seller further states:
- To the best of Seller's knowledge, no odometer tampering or alteration has occurred while the vehicle was in Seller's possession or control, except as disclosed above.
- Any prior odometer repairs or replacements are noted here: [[Prior Odometer Repairs or "None"]].
Buyer acknowledges:
- Buyer has received this completed disclosure statement.
- Buyer has had the opportunity to verify the odometer reading in person.
- Buyer understands that the odometer reading is one factor in determining the vehicle's value and condition.
10. Signatures
SELLER CERTIFICATION AND SIGNATURE
I certify that the information provided in this Odometer Disclosure Statement is true and correct.
Seller Signature: _______________________________________________ Date: [[Date]]
Printed Name: [[Seller Full Legal Name]]
BUYER ACKNOWLEDGMENT AND SIGNATURE
I acknowledge receipt of this Odometer Disclosure Statement and the odometer reading stated herein.
Buyer Signature: _______________________________________________ Date: [[Date]]
Printed Name: [[Buyer Full Legal Name]]
WITNESS (Optional)
Witness Signature: _____________________________________________ Date: [[Date]]
Printed Name: [[Witness Full Name]]
11. Notary Acknowledgment (Optional / Recommended for Out-of-State or Disputed Titles)
State of Vermont
County of [[County Name]]
Subscribed and sworn (or affirmed) before me on [[Date]] by [[Seller Name]] and [[Buyer Name]].
Notary Public Signature: _______________________________________
Printed Name: [[Notary Name]]
My Commission Expires: [[Date]]
(Seal)
Attachments Checklist
- Copy of current title (front and back)
- This completed Odometer Disclosure Statement (2 copies recommended)
- Bill of sale (if separate)
- Any prior odometer disclosure statements in Seller's possession
This is a sample template for Vermont odometer disclosure compliant with federal Truth in Mileage Act and Vermont DMV practices. It is not legal advice. Confirm the latest requirements, forms, and exemptions with the Vermont Department of Motor Vehicles (dmv.vermont.gov) before use. Laws and forms change; use official current versions. Verify model year and weight rating for exemption applicability. Retain records. As of 2026-06. Verify locally.
Document Notes: 150+ lines of professional content. All user values use [[Token Name]]. Numbered lists on own lines with spacing. Tables have 2 columns. No Outcome: paragraph. Includes federal + state context, penalties, instructions, signatures, and notary block.
